Reju Wellness Practitioner Application Form

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How did you hear about us?
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What is your primary reason for joining Reju?* This field is required.Select your type of practice and if you would also like to publish content
Holistic Wellness Practitoner
Mental Health Therapist
Creating holistic wellness and therapeutic content
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Your Profile:
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Full Name* This field is required.
First Name
Last Name
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Preferred Pronouns* This field is required.
Please Select
Male
Female
Non-Binary
Prefer to self- specify
Other
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E-mail* This field is required.
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Phone Number:* This field is required.
Area Code
Phone Number
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Race* This field is required.
Please Select
Please Select
Asian
Pacific Islander
Black
Native American
White/Caucasian
Hispanic/ Latino
Multiracial/ Mixed
Unknown/Other
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Location
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Mailing Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Current Practice Disciplines:* This field is required.
Yoga
Life coaching
Health Coaching
Diet/ Nutrition
Breathwork
Mindfulness or Meditation
Therapy
Social Work
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Current License Discipline:Please select your current active discipline
Please Select
Please Select
LMSW
LSW
LCSW
LISW
LPC
LCMHC
LCAS
PhD
PsyD
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What states are you actively licensed or certified to practice in:* This field is required.
More than one location
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Practitioner License number:* This field is required.
Must be in good standing.
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Highest level of education completed:
Please Select
Please Select
High school
Undergraduate Studies
Master’s Degree
Doctorate Degree
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Education Background* This field is required.Please list the universities, discipline training schools, or certification programs you have attended. Include the name of the institution or program, degree or certificate earned, and the dates attended.
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Years of practice:
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Focus Language:Please indicate what languages you are com
English
Spanish
German
French
Chinese
Japanese
Hindi
Other
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Please provide two professional references.
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Professional Reference (1)* This field is required.
Name, Company, Relationship, Phone, Email
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Professional Reference (2)* This field is required.
Name, Company, Relationship, Phone, Email
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Upload Resume, CV, or Practice Certification * This field is required.Upload Word (.doc, .docx) or (.pdf) only for each discipline you intend to practice on the platform.
Drag and drop files here
Select files to upload
Max. file size: 0.2MB
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Personal Biography:* This field is required.We’ll use your statement to create and review your profile for Reju. Your biography will help clients know who you are and what to expect when working with you.
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Please paste your practice website or LinkedIn profile URL.
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Your Practice* This field is required.Indicate your practice specialties, treatment orientations, modalities, and focus population demographics.
Huge
Large
Normal
Small
Ok
Ok
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Upload a Photo of your valid ID or Driver's License* This field is required.As a part of our application process, we require applicants to upload a photo ID for identity verification purposes. Please note that the information provided will be used solely for verification purposes and will be treated with the utmost confidentiality.
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Select files to upload
Max. file size: 0.5MB
Your photo ID will only be accessed by authorized personnel involved in the application review process. By uploading your photo ID, you consent to the collection and use of of this information for the stated purpose.
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You currently have an active malpractice or liability insurance
YESNO
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Please upload a copy of your liability insurance coverage.
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Select files to upload
Max. file size: 10.6MB
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Please list your availability for Reju users.* This field is required.(Ex: Mondays - 3-5 pm, Weekends 2-4 pm, etc.)
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Reju Practitioner Agreement * This field is required.By submitting this form, you agree to:
Provide affordable and accessible services at a sliding scale rate of $30- $120/ hour per session to Reju users.
You agree to work with a minimum of one Reju client OR share one original publication every 6 months
You agree to respond to Reju's prospective client's inquiries within 48 hours.
You agree to submit a background check form via SentryLink to the Reju Wellness Director tbrown@therejuapp.com as a part of your application.
You agree to maintain an active malpractice or liabitly insurance for each discipline you intend to practice on the Reju platform.
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Terms & Conditions By clicking "Submit", I attest that all of the information enclosed with my employment application is correct to the best of my knowledge and grant Reju permission to contact my references and perform a background check. Reju does not discriminate on the basis of race, color, national origin, sex, age, religion, sexuality, or disability in admission/access to, or treatment/employment in its programs and activities.
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Signature
Clear
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Thank you! Book a call with our team for next steps.
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